A man displaced by conflict in eastern DRC in a camp outside Goma, late last year.

One afternoon not long ago, MSF surgeon David Lauter, a native of Washington State, received a patient in the hospital where he’s now working in Rutshuru, in Democratic Republic of Congo’s long-troubled North Kivu province. The patient, he wrote in a recent blog entry, had been shot and “had two holes in his upper leg. His smaller hole was the size of a US quarter, coming in the back of the leg at the mid hamstring and his larger hole was the size of my fi st, coming out in the front just above his knee a bit to the outside.”

Years ago, back home, he’d treated people who’d been shot with handguns, but this injury was clearly caused by a weapon of a different order—a military-style assault rifle that was bigger and capable of both firing bullets at much greater velocity and causing much more damage. “Compared to gunshot wounds at home,” he wrote, “the ones in Rutshuru come with bigger holes and more tissue destruction.”

One wishes this type of injury were as uncommon in eastern DRC as it’s been in Lauter’s experience. Unfortunately, that is not the case. Horrific gunfire injuries happen all too frequently in North Kivu—one day last November, MSF’s project in Masisi received 22 gunshot victims in a single four-hour stretch—and in neighboring South Kivu, too, and they take a deadly toll. Still, the wounds they inflict are just one of several nightmarish hallmarks of fighting that has been so pervasive over the past two decades as to become, astonishingly, almost routine.

Though it often disappears from the headlines for long stretches of time, the crisis in eastern DRC ruthlessly persists. Taking advantage of a weak central government that’s been unable to establish rule of law and various influences from outside the country—including other governments in the region—a revolving cast of armed militias have waged seemingly constant battles against the country’s armed forces and each other, leading to the deaths of millions and frequently forcing whole segments of the population to flee in fear. Civilians have been targeted and women have been raped in terrifying numbers. Peacekeeping efforts have proven ineffectual, development efforts have faltered, and the delivery of medical care has become exceedingly difficult.

In recent months, the violence in some areas has returned to levels not seen in years. Take North Kivu: “Over the past nine months, from July 2012 through March 2013, North Kivu has endured four deadly conflicts that have killed hundreds, wounded hundreds more, and displaced large segments of the population,” says Thierry Goff eau, one of MSF’s heads of mission in eastern DRC. “In July, Rutshuru was taken by M23 [a militia composed of fighters who were briefly integrated into and then left the country’s armed forces]; in November, Goma [North Kivu’s provincial capital] was taken by M23; in February, an ethnic militia fought the national army in Kitchanga, and in March, internal factions of M23 clashed with each other in Rutshuru.” Though M23 features heavily in these recent events, it is one of many armed groups fighting in the region, some of which are becoming increasingly identified with one ethnic group or another.

Goffeau makes a point of noting that “the Congolese are incredibly resilient. They never resign. It’s a matter of survival.” At the same time, though, the cumulative impact of many years lived under the gun is evident, he says. “Children don’t go to school, soil is not cultivated, houses are abandoned, access to health care is reduced, exposure to violence is high. Long-term consequences on health, mental, education, and overall wellness are inevitable.”

MSF’S PROGRAMS IN DRC

The common trope about DRC is that it is an incredibly poor but resource-rich country, a place suffused with valuable minerals that is nonetheless severely lacking in roads, infrastructure, education, and opportunities that don’t involve picking up a gun. All this contributes to catastrophic health indicators around child and maternal mortality, particularly in the embattled Kivus.

Given the vast array of needs in the country—which go far beyond conflict to include endemic diseases and outbreaks, maternal care, and, often, basic primary and secondary care—MSF’s operations in DRC are its largest and most resource intensive anywhere in the world, and they have been for most of the past decade. In 2011, MSF had almost 3,000 people working in DRC. In 2012, in the Kivus alone, MSF worked along with the Ministry of Health in eleven different hospitals—offering services ranging from surgery to pediatrics to mental health care—and ran forty health centers, nine health posts, and four reference centers. Teams also run mobile clinics and respond to emergencies ranging from outbreaks of diseases like cholera or measles to the manifold medical needs that arise when large groups are forced to seek shelter in crowded, under-resourced, and at times dangerous displacement camps.

The rampant insecurity has affected MSF personnel. Staff have been robbed, projects looted, mobile clinics suspended or proscribed. Additionally, members of the national staff , who make up the vast majority of MSF’s workforce in the country at any given time, have at times been forced to flee with their families when their homes have come under threat. During the fierce battles that broke out in Kitchanga in late February, for instance, “it was simply impossible for our team to leave base as the intensity of the fighting would not allow anyone to move around and reach the hospitals,” says Hugues Robert, another MSF head of mission in eastern DRC. “One hospital was also damaged by a mortar shell. Most of the wounded were taken to two medical facilities and to the UN’s peacekeeping base by relatives.” National staff members had to flee as well, he notes, adding that many of them “wound up spontaneously providing medical care to the wounded” in the locations where they found temporary sanctuary.

It is, to state the obvious, an extremely complex and difficult environment in which to work, and it requires balancing an understanding of what’s needed on the ground, medically speaking, with an understanding of ever-evolving security dynamics that can change very rapidly. “There’s a constant tension among the population,” says Robert, reached on the phone when he was in Mweso in mid- April. “Last weekend, there were a lot of rumors going around, for example, so people started to question whether they should stay and protect family members or move them somewhere else, to a safe place. No one feels secure.”

MANY DIALOGUES AT ONCE

The atmosphere makes it necessary for MSF to maintain constant communication between and among teams in different projects, as well as with the leaders of the various armed groups in the area. MSF labors intensively to explain its purpose and approach— particularly its independence and impartiality—to the various groups, asking that they respect the sanctity of medical facilities and permit teams to cross front lines when necessary. According to Renaud Sander, an MSF project coordinator for the Masisi territory, “it takes constant eff ort to get acceptance from all the armed groups. Our identity as MSF makes a difference, and time after time, we stayed and continued providing care during the fighting, which helped us earn respect from the different actors.”

Though it doesn’t provide absolute protection, this has proven crucial to MSF’s eff orts in the Kivus, making it possible to accomplish a great deal under extremely trying circumstances. In 2012, for instance, MSF conducted more than 15,000 surgical interventions and admitted more than 70,000 patients across its dozens of hospitals, health posts, and mobile clinics. Teams also delivered more than 36,000 babies and vaccinated more than 2.5 million children for measles.

There’s no understating the difficulties the people of the Kivus face, but even amid the worsening violence of the past year, MSF is not cutting back its efforts. On the contrary, while continuing to monitor the dynamics between the armed groups and preparing for fighting that seems almost certain to occur in the future, MSF is conducting exploratory missions into parts of the Kivus in which it’s not currently working, trying to see if it can address even more of the needs that exist on the ground.

Behind all the strife are decades of colonization, dictatorship, exploitation, and corruption. The fighting of recent years has sown discord even further into the soil. “My perception is that 20 years of this violence has severely damaged a lot of communities,” says Robert. “The younger population, they don’t have much hope. One group appears after another to keep the fighting going. There are many issues behind it all—land issues, control over resources, political issues that involve local, regional, and even international dynamics. It’s hard to see an end to it.”

Addressing all the factors at play in this conflict—or rather, these conflicts—will take many years, if not generations, but that’s not MSF’s goal in DRC (or anywhere). MSF’s efforts are designed to maintain that balance between what is possible and what can be done safely, and to off er care to people who otherwise would go without, treating the gunshot victims that David Lauter tended to in Rutshuru, assisting births, tending to children with malaria, and caring for victims of sexual violence, all in hopes that they will survive the troubles of the day and be present should better days come.